Michael J. Isaac, Patrick Lucaci, Robert M. Laughlin, and Christopher J. Haggerty
| Lesion | Location | Radiographic appearance |
Treatment | Key points | |
| Odontogenic cysts | Periapical cyst | Attached to the apical aspect of a tooth root showing signs of pulpitis. | Well-demarcated unilocular radiolucency associated with the apex of a tooth root. | Lesions smaller than 1 cm are often treated with involved-tooth root canal therapy or extraction. Lesions larger than 1.0 cm are treated with enucleation and curettage, in addition to endodontic therapy or extraction. | Associated with tooth root with evidence of pulpitis. |
| Dentigerous cyst | Most commonly associated with maxillary and mandibular third molars. Second most common location is associated with maxillary canines. | Well-demarcated unilocular radiolucency associated with the clinical crown of an unerupted tooth. Frequently results in involved tooth displacement. Adjacent root resorption not seen. | Smaller lesions are treated with enucleation and currettage of cyst. Larger cysts or cysts adjacent to key anatomical structures may benefit from marsupilization to decrease cyst size prior to a definitive enucleation and currettage procedure. | Aspiration typically yields a clear or straw-colored fluid. Marsupilization should be considered only in large lesions due to the risk of ameloblastoma in situ or neoplastic transformation of the cyst lining. | |
| Keratinizing odontogenic tumor (odontogenic keratocyst [OKC]) | Most commonly associated with maxillary and mandibular third molars. Second most common location is associated with maxillary canines. | Variable radiographic appearances. May present as unilocular or multilocular cysts, or as a solid tumor. | Smaller lesions are treated with enucleation and currettage of entire cyst. Larger cysts or cysts adjacent to key anatomical structures may benefit from marsupilization to decrease cyst size prior to enucleation and currettage. Consider resection for recurrent lesions. | If multiple OKCs are present, consider Gorlin's syndrome. Aspiration typically yields a clear or straw-colored fluid. Wide surgical access is key to total removal of cystic lining. | |
| Calcifying odontogenic cyst (Gorlin's cyst [COC]) | More common in the maxilla than in the mandible. | Typically appears as a well-demarcated, unilocular, mixed radiolucent-radiopaque lesion. | Enucleation and curettage. | Mixed radiolucent-radiopaque radiographic appearance. | |
| Idiopathic bone cyst (traumatic bone cyst) | More common in the mandible, specifically within the mandibular body region. | Appears as a scalloped radiolucency between teeth. | Aspiration, exploration, and curretage. Curretage causes bleeding within the cavity, which stimulates bone formation. | Not a true cyst as there is no discernible epithelial lining. Not caused by trauma as previously believed. Teeth are vital. Commonly presents in childhood or early adolescence as an incidental radiographic finding. | |
| Nasopalatine duct cyst (incisive canal cyst) | Presents as a soft tissue swelling posterior to the maxillary central incisors. | Appears as a heart-shaped unilocular radiolucency (>5 mm). | Enucleation and curettage. | May cause tooth displacement and incisor root resorption. | |
| Odontogenic tumors (benign) | Ameloblastoma | Most commonly located within the posterior mandible, but may occur at any location within the jaws. | Variable radiographic appearance dependent on the type of ameloblastoma. Commonly well-demarcated unilocular or multilocular radiolucencies that may show thinning or perforation of the cortices of the jaws. Commonly associated with tooth displacement, inferior alveolar nerve displacement, and root resorption. | Varies depending on the nature of the ameloblastoma as determined upon biopsy. Luminal and intraluminal unicystic ameloblastomas may be treated with enucleation and curettage. Multicystic and invasive ameloblastomas are treated via resection with 1.0–1.5 cm margins. Lesions that perforate the cortical plates should include an univolved anatomical barrier (i.e., periosteum). Ameloblastic carcinoma is treated with larger resection margins (2.0–3.0 cm), neck dissecton, and frequently postoperative radiation therapy. | Does not cause paresthesia or anesthesia of associated compressed nerves. Treatment guidelines are adjusted based on the histopathological presentation of the lesion from the incisional biopsy. |
| Calcifying epithelial odontogenic tumor (Pindborg tumor) | Typically located within the posterior jaws (mandible > maxilla). | Radiographic appearance varies depending on the maturity of the tumor. Most early tumors are completely radiolucent. As the lesion matures, it typically demonstrates a mixed radiolucent-radiopaque appearance. Lesions may be either unilocular or multilocular in appearance. | Resection with 1.0 cm bony margins. An uninvolved anatomical barrier (i.e., periosteum) is recommended for lesions that have perforated the cortical plates. | Classically defined by their mixed radiolucent-radiopaque appearance. Often associated with the crown of an impacted tooth. | |
| Odontogenic adenomatoid tumor (adenomatoid odontogenic cyst) | Most frequently associated with the maxillary canine. | Well-demarcated unilocular radiolucency, typically associated with an unerupted or impacted maxillary tooth. Often with areas of calcification noted within the lesion. | Removal of involved tooth and enucleation of the associated cyst. | Referred to as the two-thirds tumors. Two-thirds occur within the maxilla, two-thirds occur in association with a canine tooth, two-thirds occur in association with an unerupted or impacted tooth, and two-thirds occur in young females within the first three decades of life. | |
| Benign mesenchymal odontogenic tumors | Odontogenic myxoma | Evenly distributed throughout the maxilla and the mandible. | Soap bubble appearance on radiograph with ragged, ill-defined borders. May also present as unilocular lesions. | Marginal or segmental resection with 1.0–1.5 cm margins and an uninvolved anatomic boundary. | |
| Cementoblastoma | More common in the mandible than in the maxilla. | Circular radiopaque mass associated with the apical one-half of a tooth root. Radiographic halo may be present around the mass. | Treatment consists of removal of the tooth and associated mass. | Teeth are vital. Typically presents within the first three decades of life. | |
| Ameloblastic fibroma | Most commomly associated with the mandibular molar region, but may occur at any location. | Presents as a unilocular or multilocular radiolucent lesion with well-demarcated borders. 75% associated with an unerupted crown. May mimic dentigerous cyst. | Treatment involves enucleation and curettage. | Typically occurs within the first two decades of life. Consider ameloblastic fibrosarcoma in workup. Requires long-term follow-up due to potential malignant transformation. | |
| Odontoma | May occur at any location within the jaws. Compound odontomas are more common within the anterior mandible. Complex odotomas are more common within the posterior mandible. | Compound odontomas resemble a mass containing tooth-like structures or gravel. Complex odontomas resemble a calcified, amorphous mass. | Treatment involves enucleation and curettage. | Incompletely removed odontomas may lead to wound infection as the retained tissue or residual odontoma often contains inadequate blood supply. | |
| Osteochondroma | Typically associated with the condyle or coronoid process. | Radiopaque enlargement of the condlye or coronoid process with tapered extension to the lateral pterygoid (condlye) or temporalis (coronoid) muscles. Osteochondromas involving the condyle may resemble a “shredded flag” on orthopantomogram, with the flag representing the extension to the lateral pterygoid muscle. | Treatment involves complete excision of the affected condyle or coronoid process. | Typically presents as a nontender hard mass associated with trismus and jaw deviation on opening within the first three decades of life. | |
| Central giant cell granuloma (CGCG) | Typically located within the posterior mandible, but may occur at any location. Lesion may cross the midline. | May present as a unilocular or multilocular radiolucent lesion that may displace associated teeth, expand and erode cortices, and cause root resorption. | The injection of intralesional steroids has shown early success in the initial management of CGCGs. Curettage has a highly variable recurrence rate. CGCGs that are aggressive, recurrent or refractory to intralesional steroid injections may be treated with peripheral ostectomy or resection with 0.5–1.0 cm margins. | Aggressive CGCGs are associated with pain and rapid cortical expansion due to continued growth. Nonsurgical treatment modalities frequently do not stimulate complete resolution of CGCGs, but may decrease the size and associated morbidity of future definitive procedures. | |
| Osteosarcoma | More common in the mandible than in the maxilla. | “Sun-ray” appearance due to periosteal reaction, widening of the periodontal ligament of involved teeth (Garrington sign), resorption of involved tooth roots, cortical bone expansion or destruction, and a mixed radiopaque-radiolucent expansile mass. | Definitive treatment involves the initiation of chemotherapy, followed by surgical resection with 3 cm bony and 2 cm soft tissue margins, followed by additional chemotherapy and close follow-up. | Neurosensory changes to involved nerves. 5-year survival rate of 50%. Close follow-up is required due to the frequency of metastasis to distant sites (i.e., lung and brain). | |
| Salivary gland tumors | Pleomorphic adenoma | 70% of parotid masses (most commonly within the superficial lobe). 60% of submandibular gland masses. 50% of minor salivary gland masses. | Varies depending on the location of the pleomorphic adenoma. Parotid pleomorphic adenomas are treated with 1 cm extracapsular excision versus superficial or deep parotidectomy based on the size and location of the mass. Submandibular pleomorphic adenomas are treated with gland excision to include surrounding tissue if extracapsular extension. Palatal pleomorphic adenomas are treated with 1 cm margins, including periosteum of the hard palate and fascia of the soft palate. | Typically present as a painless, indurated, mobile mass located in regions of salivary glands, such as the parotid gland, the submandibular gland, and areas of minor salivary glands (i.e., palate). Does not metastasize or invade bone. Cut-potato specimen morphology. | |
| Warthin's tumor (papillary cystadenoma lymphomatosum) | Most commomly identified within the superficial lobe of the parotid gland. | Increased uptake of Technicium 99. | Superficial parotidectomy. | May occur bilaterally. | |
| Mucoepidermoid carcinoma | Most common parotid gland malignancy. | A biopsy or fine-needle aspirate (parotid mass) is required to establish the histological grading of the lesion, and a CT scan is required to establish the depth of invasion. Histological grading and adjacent structure invasion will dictate the definitive treatment and recurrence rate. | Infiltration of the facial nerve may cause facial muscle paralysis. Treatment and recurrence rates are based on the histological grading classification (low grade, intermediate grade, and high grade). | ||
| Adenoid cystic carcinoma (ACC) | Most common minor salivary gland malignancy. Also occurs in major salivary glands. | Treatment involves resection of the lesion with wide surgical margins, nerve extirpation, and radiation therapy. | Demonstrates perineural invasion and spread, and skip lesions. Palatal ACCs require 3 cm bony margins (typically, hemi- or total maxillectomy) and complete extirpation of the pterygomaxillary space contents. Parotid ACCs require total parotidectomy with or without facial nerve sparing depending on whether perineural invasion has occurred. 5-year survival rate is 75%. 10-year survival rate is 20%. | ||
| Polymorphous low-grade adenocarcinoma | May occur at any location where minor salivary glands are identified. Most commonly associated with the palate. Typically do not exceed 4 cm in size. | 1.5 cm soft tissue margins. Lesions located within the palate are treated with removal of periosteum as well. Palatal lesions that show bony invasion are managed with involved bone resection. | A malignancy associated with slow growth and rare metastasis involving only the minor salivary glands. 10-year survival rate of 80%. |
CT, computed tomography.